March has again been designated as National Colorectal Cancer Awareness month. This annual reminder remains important, as an estimated 86,830 cases of colon cancer and 50,000 cases of rectal cancer are expected to occur in 2014.1 Colorectal cancer is the third most common cancer in both men and women. An estimated 50,310 deaths from colon and rectal cancer are expected to occur in 2014, accounting for almost 9% of all cancer deaths. However, mortality rates from colorectal cancer have declined during the past two decades, reflecting declining incidence rates and improvements in early detection and treatment.
As physicians, we know that colorectal cancer is preventable and fulfills the criteria for a disease for which screening is appropriate. Unfortunately, screening rates are not adequate to prevent this potentially devastating cancer. Only 50% of those eligible are estimated to have received colorectal cancer screenings. Even physicians and their families are not uniformly screened. Several factors may explain this failure.
Colonoscopy is the gold standard screening method for colorectal cancer. A major issue with the procedure has been the required bowel preparation. We currently have several methods to clean the colon prior to a colonoscopy: the traditional lavage preparation (GoLYTELY, NuLYTELY, TriLyte, etc) and low-volume lavage preparations (MoviPrep, SurPrep, HalfLytely, MiraLAX, etc). Each of these methods has some advantages and limitations, but we can usually select an acceptable method. Additional information on colonoscopy and bowel preparations is available on the Ochsner website (www.ochsner.org/CRS).
Economics is often an issue. Catastrophic or high-deductible health plans and copay issues limit screening in some populations. For cost-conscious patients, we must critically analyze our recommendations. Screening is cheaper than treating colorectal cancer if compliance rates are high and the costs of screening tests are reasonable.2 In perspective, the health advantages of screening should certainly outweigh the equivalent of several months of cable television or expensive mobile data plans. Current recommendations for screening for colorectal cancer range from annual fecal occult blood testing with flexible sigmoidoscopy at 3- to 5-year intervals to colonoscopy at 10-year intervals starting at age 50 for average-risk individuals. These screening methods have all shown reduced mortality.3-5
Because colonoscopy allows the physician to view the entire colon and treat polyps, it is the preferred method. Medicare realized this and began reimbursement for screening colonoscopy in 2001. Another option, available at Ochsner, is computed tomography (CT) colonography. Studies of this procedure have shown it to be reasonably accurate in detecting significant lesions, but a bowel preparation is still required, availability of the test is limited, and reimbursement issues have not been resolved. Currently, CT colonography is best for patients with coagulation issues or a technical inability to have a complete colonoscopy.
On the national and local level, multiple efforts are underway to expand colorectal screening. The National Colorectal Cancer Roundtable6 is spearheading an effort to get 80% of the eligible population screened by 2018. Groups such as Coaches vs Cancer, activities such as Get Your Rear in Gear, television programs, radio spots, print articles, and local lectures contribute to expanded screening, but physician encouragement of screening must become a daily component of our patient care. Upgrades to our electronic medical records will soon provide timely reminders on screening status. We must also lead by example and ensure that each of us, as well as our family members at risk, gets screened. Progress is occurring, but we need to continue to increase our efforts to expand screening until it becomes universal. Remember, the recommendation and example of a trusted physician remain major determinants of patient action.
Additional information is available from any of our colon and rectal surgeons or gastroenterologists and the Ochsner website (www.ochsner.org). Open access colonoscopies can be scheduled by calling one of the Ochsner endoscopy scheduling nurses at (504) 842-4060. Saturday scheduling is available to minimize the impact on patients' daily schedules.
- © Academic Division of Ochsner Clinic Foundation
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